right. so it's hard, but what you should do is try to see, try to imagine to yourself what, what's going on from their point of view? and i think the world would be more peaceful and our community would be more peaceful if we learned how to do that. instead of having debates, and this is for teachers out there, do structured academic controversies, you know? where what you do is you have people debate, their students debate a summit from the one perspective -- subject from one perspective and flip it around, have them debate the other side. and then write a position paper that, you know, involves multiple points of view. that's such a valuable thing for young people, i think. sometimes i don't tell them what side they're arguing until 15 minutes before, so they have to learn both sides of an issue.
praise. i must say though my favorite praise that i received for the book came this morning when i was reading through my e-mails and someone sent me a little note from some blogger who says, are there cliff notes for the "the emperor of all maladis". it's been my lifelong ambition to a have a book which there are cliff notes. if anyone is inspired to write cliff notes i would be delighted. i thought i would begin today, rather than talking about the content of the book, i thought i would begin today talking about process because that's more interesting. it's something you don't get from just reading the book itself, sort of a behind-the-scenes look what motivated some parts of the book and how they got written. the first i have to offer a note of apology, which this book, when it was finally
handed in its draft form was three times its length and by necessity a vast amount of information had to be cut. you can not, there is a fundamental, you know, my editor said, the 500 pages is the final limit, no more. we ended up with 600 and that was a bargain. but nonetheless, so i have to start with a note of apology saying that not every story could make it into the book. so i would welcome other attempts to write further histories of a disease that will continue to be part of our lives in the future. that said, i wanted to talk a little bit about, as i said the process of writing the book and the first moment, one of the most pivotal moments in writing of the book happened sometime early on when i was confronting the vastness of the challenge. and the vastness of the challenge is, here you have a history that spans about
4,000 odd years. there are about 100 odd characters that move in and out of the book. there are scientific terms. sometimes, in political terms, politics, and in middle of all this are this world of stories and i was having a conversation with my very excellent editor, nan gram. she said something very pivotal. she said we were talking about something different and in the end if one forgets the book publishing industries. if one forgets the vast pair fer kneel yaw that allows a book to come into play, the bookstore, marketing et cetera, in the end, a book is an amazing instrument by which one author sitting alone in a room can talk to one reader sitting alone in a room. that comment resonated very
deeply. i thought to myself if he forget for a second the vast pair fer kneel yaw in the end, 9 act of medicine, is the mechanism which one person sitting alone in a room can talk to another person sitting alone in a room, can talk to one patient sitting alone in a room. that analogy was very deep for me. because it reminded me what was, about what was essential and what was not essential and the essential piece of it was that much like a book medicine is about story-telling. medicine begins with the act, if you take away all the parafhenelia, medicine begins with someone telling me your story. that is the first thing at that when you meet a doctor, you begin to unpack a story.
as i make a claim in the book, doctors then tell a story back to you and it's this, interchange, it is an ancient interchange, problem hundred one of the most ancient interchange we have as human beings, that itself, that process in itself begins the unpacking or unburdening of an illness. long before you receive your first dose of whatever medicine you will or will not receive, it is unburdening of a story that is the first act of medicine. if we forget that, seems something very important will stop happening in medicine. and once i come to that realization, inside by this comment it began to become very clear to me how one could write this book again remembering there was a vast history here but it could be written through the eyes of patients. it could be written by telling stories. if i could tell stories that
began, whatever point of time, 4,000 years ago, if i could fulfill those stories i could flesh out these stories what seemed like insurmountable problem, which is how does one tell this history, would become actually solveable, which is tell the history by moving from story to story to story typically focusing on those who were right there. those who experienced it most directly and that is patients. now again, that was the solution in principle of the problem. that raises a second question how does one find these missing stories? how does one uncover the story of a woman who experienced breast cancer in the 1950s? remember, recount a moment in time in 1950 in fact, when a woman calls up the new york types and she says i'd like to place an advertisement for survivors
of breast cancer and "the new york times", the society editor gets on the phone, well, miss rosen, we can't print the words breast and cancer in "the new york times." what if we said survivors of group of women with diseases in the chest wall. this is 1950. when "the new york times" came to write about my book, make sure you print that, reminder for us all of us doctors that we need to be humble what can and can not be achieved here. this was the background again, these missing stories. the word that can't be uttered, a word that is whispered about, the big c. again the question was what were the stories? and one thread that came very early on is that i knew that somewhere in this story would have to be the story of one of the most remarkable women in recent intellectual history and mary last kerr.
one of many other things directed philanthropic energying. a unusual woman of her time. a entrepreneur. direct ad enormous philanthropic energy towards solving as she putting it, transforming the geography of american health, the landscape of american health. if there was one sort of central character spinning through the story it would be mary lasker. for mary lasker, very quickly found sidney farber who begins the brook. sidney farber was mary lasker's friend and scientific collaborator. if mary lasker gave political legitimacy to the war on cancer, farber provided scientific legitimacy for the war on cancer. so the book begins with sidney farrer about. sidney farber was a pathologist. we begin in the 1940s.
so-called the doctor of the dead because primarily pathologists in the 1950s would perform autopsies. it, he was a pathologist who specialized in children's pathology and typically bodies of children who had died in the hospital would be wheeled down into his basement laboratory. the laboratory was no bigger than about 12 feet by about 12 feet. kind of a frozen cube at the bottom of one of the buildings. that's where we are in 1948. and then, farber became interested in trying to find a mechanism or an understanding of a disease which was extremely lethal, a swiftly lethal form of cancer. that was childhood acute lymphoblastic lukemia. it not always but typically affects children. in 1950s almost uniformly
lethal. 100% mortalitity. often kids would die, would be diagnosed within, and die within a span of a week, two weeks. sometimes they would live longer and do soon after. one of the reasons leukemia like many other forms of cancer could be counted. as i talk about in the book science begins with mesh mur shaent. this was a time before cat scans and mris so it was very hard to count the size of an internal tumor because it was buried inside. leukemia because of cancer of blood you could form a bone marrow biopsy or in the bone marrow or the blood could see the depth or life of the cell and thereby you could say this therapy worked or didn't work. it was an objective mechanism one could have a conversation about the increase or decrease of lee keep mick cells.
farber figured out would find a chemical that could would kill the leukemia cells and launched history of chemotherapy. he didn't have the chemical. he fantasized about such a chemical. turns out there was indian chemist, a chemist born in india and he had come to boston to harvard to study at the school of tropical health. now, what he didn't know was that, as we all know, there is nothing tropical about boston. so yellow was stuck in the middle of, he arrived in winter. he was stuck in the middle of winter. he couldn't found a job. he found a job in fact cleaning urineals. that is best job he could get. somehow through series of exchanges he found a job in the department of biochem mystery. he made several fundamental discoveries. yellow discovered atp.
he discovered as some of you plight know is very important molecule and several other seminal discoveries. because he was indyap he was denied tenure. he was sent off sent off from harvard, sent himself off to a pharmaceutical company in new york called lederle. a subbranch the american cynamid company. he took up a problem very great interest to him. he began to sin that advertise -- synthesize many site inches minutes. one vitamin he was particularly interested in was called folic acid. and in the past, an english physician, a young woman, had figured out that folic acid was responsible for the growth of normal blood cells. so in or the words often in women, particularly pregnant
women, deficiencies if you didn't have enough folic acid your blood wouldn't grow normally. farber pud all these things together piece by piece. wait a second if folic acid is required to make normal blood grow, could it be if you block folic acid you could block the growth of malignant blood which is lukemia. he said if folic acid is the key factor for the growth of normal blood cells, could one take an anti-folic and thereby block the both of lou keep mick cells. this was the drug yellow discovered in process finding folic, found opposite. synthesize ad anti-folic. farber wrote to yellow in new york. he sent him an anti-folic and farber began to inject children with the anti-folic and demonstrated for one of
first times in history a remission in childhood lymphoblastic lukemia. and farber comes out of his basement and in fact the idea of using an anti-metabolite, anti-folic is central to the way we perform therapy today for many forms of cancer. that is the backstory. but the front story was if that is the case, if this is the interesting steer about foal late hoe was the first person to receive folic acid. i wanted to tell by the eyes of child receiving chemotherapy not just the scientist administering chemotherapy. seems to me that would violate the fundamental principle of the book. wait a second i have no idea who this child is. i'm on page 60 and i can't find the first patient or first series of patients with lukemia. the only thing i knew about this child was that he was three years old and that he
had lived in boston and his initials were rs. that was all that was in sidney farber's paper. i was in boston. i began to send out e-mails on list servers, if you happen to have, if you happen to know a child called rs with lukemia in the 1940s please call me, write to me, et cetera, et cetera. months passed by and there was absolutely nothing. there was no response whatsoever. so and i kept saying to myself, i'm on page 60. this book is never going to get written. and then i got dejected and i would, went on a vacation to my parents house in india. and someone said to me, yella the chemist has one biographer. written only biography of yella. he said his biographer is 85 years old but lives three
blocks away from my parents house in india. go talk to why. elaa's biographer. find i will talk to the biographer. we have an conversation and talk for about an hour and about his chemistry. i'm about to leave. i don't know if you're interested i was in boston in 1950 visiting sidney farber's clinic order to compile the biography. i have a roster of all his patients with lukemia. and, this was, i was, stunning moment for me. and out of his files came a series of patients names. and a series of pictures. that's how i found this child, robert sandler, this missing child. and rs was robert sandler, the 3-year-old child and in fact the boston sunday herald had printed a picture of him in 1948 when he had just begun to respond to chemotherapy. again this was historic
moment for medicine. none of this is searchable. this is time not indexed. so i would have never ever discovered him. in a sense this became a met at that far for writing of this book which is that you might look for something and yet in reality you might find it 6,000 miles away. the second metaphor was that things always come around. there's a circularity to this process. there is second quarter lair trito history. and so i came back to boston armed with the name of this child and then using the medical records and using the boston direct tries, address book, i could find his parents name. using records of the death records of boston, certificates of death which are publicly accessible i could find, i could find exact time he had died, where he had died, where he had been buried, where he had lived, et cetera, et cetera. all of sudden the story that
had vanished came alive for me and that's how again, that is how this book got written. so the first passage i'm going to read to you what i call, now that i've given you the hint th the behind-the-scenes look, the front of the scenes look what happens when you've done all the legwork as it were and found this child, how then you can construct a story. because again, piece by piece, it, for me it all started coming together. here's a section which i now reconstruct the story of this child having visited his house. seven miles south of the longwood hospitals in boston the town of dorchester which is where robert sandler lived as it turned out is typical sprawling new england suburb. a triangle to the industrial settlements to the west and green bays of atlantic to the east. in late 1940ses waves of jewish, irish immigrants
soled in dorchester that snashged their way up the avenue. part of the writing this sentence was, now i could go back into the history of dorchester and read about that history and thereby reconstruct and it turns out that robert sandler's father was a ship builder. again he was now linked into the larger history of the town of dorchester. dorchester reinvented itself as quintessential suburban family town with parks and playgrounds along the river with a golf course, church and synagogue. on sunday afternoons families converged with franklin parks to walk through the parkway or watch ostriches, polar bears and tigers at its zoo. a kind of small note here, when i was writing all of this i kept thinking i went to robert sandler's house and i looked out of what might have been his window. i don't know exactly where he lived in terms of what floor but looking out it looks into franklin park which was at that point of time part of it was a zoo. i kept thinking to myself if
i was a 3-year old child what would i remember most about that zoo? i had a 3-year-old daughter then and i kept thinking what would it be? i thought to myself it would have to be the animals. so the it took only a couple of reading to figure out there with ostriches. they come newly to dorchester park zoo. what was very nice again, history so circular. someone came to me, i was doing one of reading in seattle, many so one came to me, said how do you know there were ostriches to in the zoo. said so nice as writer, filed away back in of my cabinet a little article about the fact there were ostriches at dorchester zoo but very odd things that give you pleasure as a writer. in the house across from the zoo a the child after ship worker in the boston yards fell mysteriously ill with a low-grade fever that waxed and waned over two weeks without pattern increasing lethargy and pal lore. robert sandler was two years old.
his twin, turned out he had a twin was in perfect health. truth being "stranger than fiction" we talk a lot in this book about how genes are activate tore and activated to cause cancer. if you want to find a mechanism to describe this, to describe the role of carcinogens and internal genetic abnormalities there can sometimes be a family history you probably choose two identical twins and one woe develop cancer around the other would not develop cancer and that would allow to begin to enter biology what makes one twin have cancer. i didn't ask for this. yet of course there is a twin. robert sandler has a twin and therefore sets up dpast for this discussion to happen down the road what does a twin mean? what does a twin mean in genetic terms for cancer? i will come to that now we enter farber's paper, again and reminder how dense, how incredible medical writing
can be. in a very cold clinical paper there is the story of human being told. whenever doctors exchange clinical papers, what they really exchanging again i think are stories. again disguised stories in some way. stories dressed up in technical language but ultimately exchanging stories. we returned to farber's paper. literally restating what's in that paper. 10 days after his first fever robert's condition worsened significantly. his temperature climbed higher. his complexion turned from rosy to milky white. he was brought to children's hospital in washington. his spleen was visibly enlarged heaving down like an overfilled bag. a drop of blood under farber's microscope revealed identity of his illness. sounds of immature lymphoid blasts were dividing in frenzy. like tiny clench and unclenched fists. sandler arrived at children's hospital a few weeks afar per received his first package from yellow at
lederle. in oct 1947 he injected sandler with paa, the first of yell la's anti-foal late. parents are informed by a trial but children are almost never informed or consulted. nuremberg code for human experimentation requiring explicit voluntary consent from patients was drafted in august 9th, 1947. literally one month before this drug, before the paa trial. doubtful farber in boston heard of required consent code. the drug had little effect. he develop ad limp, the result of lukemia pressing down on his spinal cord. joint aches appeared and violent migrating pains. the lukemia burst one of his bones causing a fracture and unleashing blindingly intense inscribable pain. by december, the case seemed
hopeless. the tip of sandler's spleen dropped down to his pelvis. he was withdrawn, listless, swollen and pale on the verge of death. on september 28th we know that from sidney's papers farber received a new version of foliate. this was a chemical with a small change from the structure of paa farber snatched the drug as soon as it arrived and began to inject the boy in it. hoping at best a minor reprieve from his cancer. the response was marked. the white cell count which was climbing astro in i canly. nearly 70,000 in december, suddenly stopped rising and hovered at plateau. even more remark i about the count started to drop. the lukemic blasts trickled out and all but disappearing. by new year's eve the count was 1/6 of its peak value bottoming out at nearly normal level. the cancer hadn't vanished.
under the microscope there was were still malignant white cells but they had abated. on january 13th, 194 sandler returned to the clinic walking on his own for the first time in two months. his spleen and liver shrunk so dramatically his clothes, farber noted had become loose around the abdomen. a little observation in a clinical paper. this is sidney farber writing and he says, in his remarks, he says, rs's clothes are looser on abdomen. what a amazingly vivid of vivid description. if you want to describe the remission of lukemia of child in remission. this child was swollen his mother had to make new clothes. now the child with the spleen receding his clothes had become loose and that is his remission. you don't require very much to go into a medical paper to reconstruct a story that is so vivid. his bleeding had stopped.
his appetite turned after news as trying to catch up on six months of lost males. by february farber choled noted the child's atletness and activity were equal to his twins. for a brief month robert sandler and elliot sandler seemed identical again. like all stories this one also has an eppy log. the eppy log is more amazing than the story itself. 10 days after book was published i got a phone call from my editor and she said, you need to sit down because this is very important phone call. i was writing a grant in my on my computer and i sat down it was elliot sandler on the phone. and he had walked into a bookstore, never having known about this book remembering the story of his twin who had died at three years old and people who have copy of the book know that the book opens with to robert sandler, 1945 to 1948
to those who became before and after him. he opened the book. he lives in maine. i would have never found him. he lives in maine. he opened the book and saw his brother's name, this brother had vanished from his life at three years old and he, actually moved to tears then. and he went back and he told me this amazing story which is, his mother, helen, whose picture in the book because i had found her picture from the saturday morning post, "saturday evening post", helen, helen and robert and elliot and the whole family was jewish and this was a time when, this was, still remains, that she was, she was a deep believer and as, many of you might know, opening a body, performing an autopsy after death is considered a violation of sanctity and helen didn't want her child to be autopsied but farber was a pathologist and only way he
knew he could learn from the first remission was to perform an autopsy. so farber had begged helen sandler to let helen, to let her open robert's body and perform a normal autopsy. she had refused and finally had really begged her for the sake of medical history, medical science and open this body up. she said fine, do it. she said through elliot she told me this decision haunted her for decades, for decade she would think to herself it was the wrong decision. so, i think the finest praise i got from my book is from helen sandler, indirectly said to me that the book brought her story to a close. she said that now that robert sandler has found a place, rightful place in medical history, it was as if her decade-long haunted memory had come to an end. i think that's in some ways finer praise than any, any than i have received and perhaps most moving thing
happened to me around the book. i think i, i have time for one more massage i'm -- passage i'm going to read. this is from the end of the book which takes up a very different kind of challenge. the first kind of challenge that i described to you is the challenge of story-making which is how do you populate a book. so it is the challenge that appears in the content. a book like this as face as very different kind of challenge and that's a challenge of summary making which is at the end of the book how do you summarize 4,000 years of history? how does one prepare to give, how does one tie up all of this. quick answer there is no simple solution that is one thing you learn in the book. one of the challenges in the book there is no pat answer. answer. i didn't want to write a book how do you cure cancer, eat broccoli or some nonsense like that. here i take up that challenge by actually
performing a thought experiment. and i recount the story, earlier in the book i recount the story of a persian queen who is described in no less than about four reasons in heroditus becomes one of the earliest descriptions what might have been breast cancer. we don't have a word for cancer in this time. heroditus is description of the early history of the west, particularly focusing on greece, sends a little bit of a message, throws her off in two or three times but he describes this idea that the queen of persia developed a malignancy, a swelling in her breast, a mass in her breast as some people translated it. her response, intensely contemporary prose, her response she was so ashamed
of it she hid herself in her shame. remember 1950, fannie rosen calling up "the new york times." she hid herself in her shame and she wouldn't let anyone exam inher breast until a greek slave intervenes and promises to cure her. he does cure her. if so he probably does so performing one of the first recorded mastectomies or lump peck mys of breast cancer. she is very grateful and as a return favor she tells him she would persuade her husband, the king of persia, who is invading the eastern border of persia, will persuade him to invade the western border persia in towards greece so he can return back to his native greece. in doing so, this launches the grecco persian war. here is this woman, who, i'm actually quoting, literally quoting from the histories. this is the moment in the histories when, when the
face of persia as it were turns from its eastern face to the western face because of this illness that she has. he dedicates four or five lines. this launches the early history of the west, the grecco persian war and turning of the face of persia away from its eastern border toward its western border launches as we very well know now the famous grecco persian wars. so we now know, 500 pages later, return back. recall otas. s. a the persian queen likely had breast cancer in 500 bc. she is cancer's doorian gray. she moves through the arc of history, her tumor frozen in stage and behavior remains the same. her case allows us to recapitulate past advances in therapy and consider its future. how has her treatment and
prognosis shifted in the last 4,000 years and what happens to her later in the new millennium. toss backward in the clinic egypt in 2500 bc. i am hoe ten has name for illness. a we can't pronounce. provides diagnosis but there is no treatment he says, closing the case. in 500 bc in her own court, she self-prescribes the most primitive form of a mastectomy performed by her greek slave. 200 years later, identifies the tumor as give illness a name. this is it derivation of the name cancer. because hippocrates, imagines cancer as crab and blood vessels spread out like the legs of the kra crab under the sand. right from its inception, cancer is metaphorical disease. metaphorical ideas of cancer permeate this illness.
1,000 years slash by. the tumt more keeps growing relapsing and waiting and metastasizing. medieval surgeons have little idea of the disease. these are real documents drawn from historical texts. ing from's blood lead plates, holy water, crab paste caustic chemicals as treatments n 1778 in john hunt's clinic london her cancer is a assigned a stage. late advanced invasive cancer. for the former early localized cancer hunter recommends a local operation. for the latter he recommends remote sympathy. when she reemerges in 19th century, incounters new word of surgery. in the clinic in baltimore in 1890 treated with the boldest and most definitive therapy thus far radical mastectomy and removal ever the deep chest muscles and
lymph nodes. in early 20th century, by the way that treatment i go through that story of that in the book turns out to be essentially a failure. takes 90 years, 90 years before patients and doctors can begin to convince themselves to really put the idea of radical breast surgery to test. when it is put to test, 90 years after its invention, 500,000 women treated with later turns out to be no different from nonradical surgery. in the early 20th century, radiation oncologist trying to obliterate the tumor using local x-rays. another century of surgeons. the cancer is treated locally with simple mastectomy, or lump peck my with simple radiation. the surgery is followed by combination of chemotherapy to diminish chance of a relapse. her tumor tests positive. we're recapitulating things gone through in the book. tumor tests positive for the
receptin. in 198 of her tumor is further discovered to too be too amplified in addition to surgery, radiation, and toe mocks fin. she is treated with targeted therapy. impossible to enooum rate the precise tiff impact of in the survival. does not allow direct comparison between otasa's fate in 500 bc and the fate in 1989. surgery, targeted therapy, have likely added anywhere to between 17 and 30 years to her survival. diagnosed at 40, she can reasonably be expected to celebrate her 60th birthday. in the mid-1990's management of the breast cast send takes another turn. diagnosis at early age and ancestry raise whether she carry as mutation. these are terms introduced and passed in the book. the genome is sequence and mutation is found.
enters intensive screening program to detect appearance of tumor in unaffected breast. two daughters are tested found positive for prc-1. lateral prevent the development ever invasive breast cancer. for the daughters the impact of screening and prophylaxis might be dramatic. a breast mri might identify small lump in one daughter. might be found to be breast cancer and surgically removed in preinvasive stage. other daughter might choose to undergo previous lactic mastectomy. she might live out her life without breast cancer. each one of those sentences corresponds to seminal clinical trial. basically as oncologist would know. each one. sentences would refers back to major single clinical trial that proves or disproves a particular way of management prc-1 positive or 2 positive, er positive or er negative breast cancer
does so i hope in a way understandable and somewhat humanized. move her into the future now and in 2050, she will arrive at breast oncologist clinic with a flash drive containing entire sequence of the cancer genome, identifying every mutation in every gene. the mutation might be organized into key pathways. algorithm might identify the growth and survival of cancers. therapies might be targeted to prevent relapse of her tumor after surgery. she might begin with one combination of targeted drugs. expect to switch to a second cocktail when the cancer mutates and switch again when the cancer mutates again. she will likely take some form of medicine to prevent, cure or pally eight her illness for the rest of her life of the this is progress by we become too dazzled by her survival it is worthwhile putting it into perspective. give her metastatic pancreatic cancer in 500 bc.
the prognosis likely changed by more than a few months in 500 years. if she develops ghoul bladder cancer that is not amenable to surgery her survival changes only marginally over centuries. if her tumor had metastasized or receptive negative, unresponsive standard chemotherapy, then her chances of survival would have barely changed since the time of00er's clinic. if cml, or hodgkins disease in contrast her lifespan might have increased 30 or 40 years. part of unpredictability about the trajectory of cancer in the future we do not know the biological basis for. we can not yet fathom what makes pancreatic cancer or gallbladder cancer marked ily different from cml or her breast cans ir. what is certain however, even the knowledge of cancer's biology is unlikely to eradicate cancer fully from our lives as richard
dole suggests as epitomizes we might as well focus prolonging life and rather than eliminating death. this war on cancer might best be won by redefining victory. that is the second passage. how are we doing for time sometime for one last passage or wrap up? this is this passage was probably hardest for me to write. it in fact goes back to the question john talked about why i had written this book. it was written as answer to the a question that a woman had raised so we return to the story of that woman. this is a, an incredible woman who i treated while a
fellow in boston and she had abdominal sarcoma and had relapsed and had another remission, another relapse, another remission. incredible remissions by the way caused by what was then a new drug called or gleevec. striking remissions. and she had, was unbelievable character. she was a psychologist. she had essentially followed the trail of this drug throughout the country, moving from one clinic to the next clinic enrolling in clinical trials. getting information on the web. creating her own community every time around herself. she would engage this community and ask questions and then pull herself into those trials. she had, there was a, she had at one point of time she was receiving chemotherapy using one of those drugs while living in trailer home. she found herself homes like this. move onto the next one. almost like she was creating her own little trail all
around the country. unbelievable person. and then finally, she had had her last response and then her tumor became completely resistant and would not respond to even newest forms of therapy. so, so this is my, this is the last time i see her. so i'll, i will pick up the story. the new drug, this is the last time she had a drug produced only temporary response but did not work for very long. by february 2005, her cancer spiraled out of control growing so fast she could record its weight in pounds as she stood on scales every week. eventually her pain made it impossible for her to walk even from her bed to the door and she had to be hospitalized. my meeting with germane that evening was not to discuss drugs and therapies but to make honest reconciliation between her and her medical condition. as usual she beaten me to it. when i entered her room to talk about the next steps. cut me off.
her goals were simple. no more trials. no more drugs. six years of survival she eked out between 1999 and 2005 had not been static frozen years. they had sharpened, clarified and cleansed her. she severed her relationship with her husband an intensified her bond with her brother and an con psychologist. her daughter, a teenager in 1999 and mature sophomore at a boston college grown into her ally, confidante, sometime nurse and her closest friend. cancer breaks some families and makes some, germane said. in my case it did both. she wanted to go to alabama to her own home to die the death she expected in 1999. when i recall that final conversation with germane, embarrassingly enough the objects seem to stand out more vividly than the rooms. hospital room with smell of disinfectant and hand soap. unflattering lights. table piled with pills, newspaper clippings, nail polish, jewelry and
postcards. standard issue plastic hospital picture filled with a bunch of sunflowers perched on a table by her side. germane as i remember her sitting by the bed, one leg dangling casually down and usual combination of clothes and large, unusual pieces of jewelry. her hair was carefully arranged. she looked formal, frozen and perfect like a photograph of someone in the hospital waiting to die. she seemed content. she laughed and she joked. she made wearing a nasal gastric tube somehow effortless and dignified. only years later in writing this book could i finally put into words why that meeting left me feeling so uneasy and humbled. gestures in that room seemed larger than life. objects seemed like symbols and germane herself seemed like an actor playing a part. nothing i realized was incidental. the characteristics of germane's personality once seemed spontaneous and i am pulse sieve were in fact
calculated almost responsive responses, almost reflexive responses to her illness. her clothes were loose and vivid. they were decoys against the growing outline of the tumor in her abdomen. her necklace was distractingly large to pull attention away from her cancer. her room was topsy turvey with baubles and pictures. filled with flowers and cards stacked to the wall because without them it would devolve to anonymity of any other room in the hospital. the tumor had invaded her spine and begun to paralyze her other leg make it impossible to sit any other way. her casualness was steady, jokes were rehearsed. it made her anonymous and seemingly humorless. to die an unsightly death in hospital room thousands of miles away from home and responded with a vengance, moving one step ahead to try to out wit it. like watching someone locked into a chess game.
every time germane's disease moved imposing yet another terrifying constraint on her she made equal move in return. the illness acted and she reacted. it was morbid, hypnotic game that taken over her life. she dodged one blow only to be caught by another. she too was like carol's red queen, peddling furiously to keep still in one place. germane seemed that evening to capture something essential about the struggle against cancer. to keep pace with that ma la did i keep reinventing and inventing and unlearning stratis about. she fought cancer, canningly, madly, zealously, channeling all the inventive energy of generation of men and women who fought cancer in the past and would fight it in the future. her quest for it a cure taken her on a limitless journey chemotherapy, clinical trials halfway across the country to a landscape more desolate,
desperate and dischoir oating than she even imagined. she deployed every last morsel of her energy to the quest mobilizing and remobilizing the drugs of her courage, someoning will and wit and imagine until the final evening she stared into the vault of her resourcefulness and found it empty. in the haunting last night hanging on to life by no more than tenuous thread summoning dignity as she wheeled herself to the private is her bathroom encapsulated the 4,000-year-old war. june, 2010. thank you. [applause] >> dr. is, don't start the question until you have the fike known.
-- microphone. because this is filled for tv for privacy reasons, don't ask any personal questions, thanks. >> personal medical questions. can ask questions about me. actually i would start, if i may, by asking john a question and that is, john, tell us a little bit how, what's happening at national cancer institute? you've come here from washington. tell us a little bit what is happening in the national cancer institute in terms of this new administration and this sort of sputnik comment and what you imagine would be happening in this administration with respect to cancer. >> thank you. kpol lent question. i first wanted to comment. i was most impressed by your eloquence and ability to communicate. i really think by being able to educate america and the world about cancer it's really my hope that someone in a field other than medicine will probably be the one to find the answer
to cancer, like nitrogen mustard gas was found on the battlefields. one lesson i learned at ucsf, very often the medical students, the youngest trainees who ask the most provocative questions and who move the field of medicine forward. i really wanted to congratulate you. really, i was most impressed during your discussion of serendipity. i really hope there may be the opportunity for someone here tonight to think of new answers just like the apple slogan, think differently. there's a lot of excitement in washington, d.c. right now. there is a pitched battle to either change or repeal the affordable care act but one area that continues to move forward is the amazing amount of work, clinical trials and studies being undertaken at the national institutes of health and national cancer institute. i hope that the budget will
be able to be approved and funding will be preserved to continue all the incredible work that is being performed at the national cancer institute. the institute offers tremendous hope for patients from the entire world and it appears that the commitment of the obama administration to discovery, to innovation, will continue. so i think that for cancer patients all around the country and the world that there are many great things yet to come from that institution. >> what are the battles? who is fighting what? >> the battles are political. they're about how we are going to change or repeal the affordable care act and one of the, there are many strategies, i would turn your attention to an article
from "the wall street journal" last year about the strategies to either defund, disallow, repeal, or to change the legislation that was passed last year. it really is my hope that we can be constructive and to move above the acrimony of the debate and identify those portions of the law which are working wall and identifies the ones that need to be improved and to keep this process of health reform moving forward. >> thank you. absolutely vital. yes, questions? >> i'm dr. jordan wilbur. i'm an old time pediatric oncologist. what i want to do is make a comment. you wrote a fantastic book. but i do personally, most of the people -- [inaudible] and you have them right on. >> thank you.
>> right on. thank you very much. >> thank you. one of the things again, with the constraints, because of constraints of time, to draw a character in a book like this, one of the ways you, really relies on lots of primary interviews. aside from archival research. a lot of primary interviews. i think there are about four or 500 interviews went into the book, carried on over time. even painting a picture of sidney farber was to do that. to come at him from different angles. what is important that human beings are complex. even a character like farber, a lot of people didn't like him. he was an unpleasant character to some. that is important to convey because otherwise you begin to write a history that is not real. thank you for your comment.
>> have you ever been a doctor in a war? >> that's a good question. not in the ends sense that you might understand war. i have never been a doctor in the military forefront. but one might say that this is also a war, in sense that, when, when we sometimes we fight wars between people and human beings fight each other but sometimes we fight even more important wars against things that we can't see and i might add that cancer is one such entity. i don't like using the word war sometimes, because, it feels as if, then, patients become soldiers, and if you don't survive, you become a loser, in such a war. i don't like using that metaphor. but for some people it
works. for some people really imagining us in a battle against cancer is important. and my usual approach to all of this is if that is metaphor works for you, use it. who am i to tell you what metaphor works for you. so, yes, quick answer is i've never been a doctor in a war but i have been a doctor in this more abstract, abstract war. and, there are other wars that are also being fought now against more abstract entities, political wars, and part of that is also part of this book, how does one fight a political war? how does one create strategy which is not only scientific strategy because one thing we know is that if we are to engage cancer, whether it be a war or not, if we are to engage cancer, the solution can't just be a scientific solution. it will never be a scientific solution. there will have to be a political solution, cultural solution. all of this comes into the book. eradicating tobacco is not,
one doesn't require scientific solution. one requires a cultural and political solution. solving the genome of pancreatic cancer is completely different but requires another kind of strategic element. so every piece of us, every piece of us as society, every piece of us as human beings is engaged this and everyone can contribute i think. >> you seem to be speaking primarily of cures of cancer s i'm wondering about prevention. seems to be increasing amount of research going on. vitamin-d is big popular issue right now. could either one of you comment on your outlook toward the preventative efforts that are being made and any optimism there? >> well, i have several comments about that. there is large section of the book that deals with prevention. make no mistake, in fact one
of the most historically in fact, one of the most seminal moments in the war on cancer is when this idea of fighting a war, curative battle began to fade away and people began, research was focused on prevention that continues today. my thoughts about prevention are many. i'm not going to talk about them at great length. i'm going to make two comments. one comment is that it remains shocking to me that the most preventable carcinogen is still at large. here we are fighting complicated battle on the hill about how to do this, that, or the other, about health care costs. meanwhile, the, the largest known carcinogen, you know, there's a great irony in all of this. people come and talk to me about radon or, you know, some, known carcinogens, fully acknowledged carcinogens but it's a
little bit like we're not talking about the huge elephant in the room which is toback key. so, -- tobacco. my quick answer to the question is, some of the battle against preprevention will be political and cultural battle. second point i want to raise which is very interesting which seems the silos of prevention and treatment and cancer biology are collapsing. in many different ways. and i think that's very encouraging. in other words we used to think that cancer prevention people used to live in one chartment and cancer treatment people used to live in another partment and others lived in a separate partment. i will give you an example. tomoxafen is very good example of that. this is drug created originally to treat advanced stage metastatic positive breast cancer but turns out to have a role in prevention. you can use tamoxifen in
preventative agent, in properly identifieded focused population. tools at mammography which were invented as diagnostic tools to diagnose breast cancer can be used in a prevent sieve setting. in fact even the genomics, cancer genomics, understanding of cancer genomes and cancer genes has increasing role in prevention particularly on breast cancer. so there is a way in which the new molecular biology of cancer forcing us to rethink the silos. that is very good. it will allow us to think about prevention that just doesn't relegate prevention on one end of the spectrum and treatment on the other end of the spectrum. that has bp happening for a while and really encouraging to me. any comments. i agree entirely. i'm a surgeon, if we can cure cancer if we catch it in time. as surgeons we burn them, froze them, used
ultrasounds. cut them apart and made vaccines. if we can catch them early enough, we can cure them. to me it's, the question is about the prevention of recurrence and what we have haven't solved you can have a tiny tumor and remove it in its entirety but months or years later you discover it spread all throughout the body. conversely i've seen the largest time morgue you tumors that you remove surge cliff and they never recure. the next step from the surgical prevention is, prevention of met it is a at that sis and recurrence. >> [inaudible]. >> viruses and bacteria evolve so there for the war against them is never over. it is always temporary victories for decades. do cancers evolve with your 5,000 year look? >> well, cancers have all
been microscopic sense. in other words, cancers are evolving inside the body of the human being that the cancer is in. in other words, within, within every tumor there is kind of a darwinian battle going on, even without treatment. so, within every tumor there are clones growing out which are resistant for instance, to escape your immune system. within every tumor there are clones that will move into other parts of your body. when you take chemotherapy, you will kill you might kill many of cells but some cells that escape and therefore will eof involve out of that. so, cancer, we talk about this is fundamentally darwinian illness that is in fact part of the secret of how, unbelievably successful cancer cells are in invading. every time, kind of, we come back to the red queen metaphor. every time you are doing
something, cancer sells are pushing back, or shouldn't use language like that, but cancer cells are evolving and it is much like treating a disease with, it is much like treating bacterial illness or much like treating a disease with viruses, constant mutation and evolution happening. like the ga lop gas trapped inside the body. . . >> because you don't know very much. do you have any comments on that? >> well, my comment, in general, that's an unfortunate situation.
that's a situation that i hope we don't find ourselves increasingly over time. i hope that, i hope that we have, given the pressures of time and money that are occurring in health care, i hope that we have the time to listen to stories and figure out how to best treat not a statistical entity, but a human being. and i have to say it's very tough. sometimes it requires, it requires a kind of listening skill which i think we as doctors have forgotten. some people might not want a certain kind of treatment, um, and it's very hard for physicians to listen to that. we've almost forgotten that listening skill. i hope that doesn't, i hope that we have a way to keep that in medicine. did you have any idea? i mean, how does one -- >> well, my thought was i didn't feel that my doctor wasn't listening to me, i felt like i
have not been someone who studied cancer my entire life. i knew people who had it, but i knew very little about it. to really get to the level where i could ask a question and make some definitive decisions, i would have had to move so fast, i would have had to be reading up on everything. so when it gets right down to it, i have to trust my doctors which, of course, i do. and i chose doctors that i trust. but i think as a patient, a patient does feel pretty much out of control. >> oh, i mean, and that's fundamentally the case, right? it is the case that one feels out of control. you know, um, i think, i think this is -- i mean, i really think this is one of the fundamental challenges of medicine, how does one, how does one involve the patient in a way that's respectful of the patient's wishes, but on the other hand, doesn't make you
feel -- it's your job to be the expert, you know? once it becomes your job to be the expert, then in some sense the process has defeated itself. there is a reason behind someone to colate all the information, and there's a huge amount of information. so i think in some ways i don'tt know the answer. i have two general strategies. one is, ironically, at least in my personal practice i find patients become more confident when you don't know something. it's a peculiar irony as opposed to saying, you know, you know something. it's a peculiar irony of med medicine, of course, much like readers can detect a false note in a book, patients can detect false confidence in doctors. so, ironically, the best way to approach, to build confidence is to be humble about what's known
and not known. that's my personal practice. um, and the second thing, i think, in some ways it is, in fact, a restoration of faith, and this is as it relates to my practice, in saying let me be the person who has the information, but you give me the direction. so don't spend your nights looking on the web or the blogs pause that's not -- because that's not what will allow the healing to occur. there's enough on your already. let me be the person who gives you the information, and you be the guide for the information. i think that relieves patients. they don't have to be the person who is the expert all the time because no one's the expert, you know? i'm not the expert. i know a little bit more, but i'm not the expert in your choices and directions. so that's my strategy.
but, again, i think it involves active listen chg i think is very hard to do in these times. >> i learned that web research is the kiss of death. >> i know. [laughter] it is the kiss of death, i think. >> do you think that the vast quantity of chemicals that are being used in various processes are contributing to a increase in the incidents of cancer? >> it's a tough question. i think that some chemicals may be contributing, um, but i think that the -- but i think, on the other hand, one has to be careful about this idea of hypercarcinogennic environment because it creates a kind of panic about the environment that i actually don't agree with. so my general thoughts about this is that every chemical, particularly those that reach a certain concentration, in our environment need to be quite rigorously tested. in fact, our testing mechanisms are improving. we used to perform a very primitive way of testing for
carcinogenic agents. it really relies on the fact that these chemicals cause mutations. not all directly cause mutations in bacteria. it's an important test, in fact, developed at berkeley, but it's a very primitive te. we have much better tests for that. i also disagree with this idea that, i mean, every chemical needs to be tested is exactly the right thing to say. but i disagree with this idea that, you know, we have a generally more carcinogenic environment because we need to find what those precise carcinogens are. it's a little bit like saying, you know, the water is carcinogenic. that's okay, but i have to drink the water. or someone says the air is producing cancer, but i have to breathe the air. you have to tell me in a very want tative and realistic sense that the dose that's available,
this molecule in the air is causing cancer so i can remove that molecule. my plea is let's be specific about these kinds of claims. what is the chemical? how can we remove it? what role does it play in normal leaves? and then remove them from be our environment. >> i had a question similar to that. >> sorry. >> was i supposed to start now, or am i supposed to wait? [laughter] i have a bit of education which always makes a person dangerous. so my question, similar to his, but i'm interested in avoiding the paranoia that the press encourages. so i wonder if there's some sense you have about the percentages of cancers that are, basically, what i would call natural mutations, things that running around living in a clean
room all your life really won't cure, and what percentage -- and i'm sure these are different for each type of cancer like smoking we do know the answer. but excluding lung cancer, is there a percentage either inherited or that come with age and which ones might be industrial carcinogenically-oriented? >> so that question is, as you can imagine, is an extremely difficult question to answer. it's answerable for rare cancers. so there's an old adage in epidemiology which is that large, rare risks are much easier to assess than small, common risks. so in other words, you know, if there's a sudden epidemic of liver cancer which is associated with a particular toxin, right? those risks are very easy to determine and, therefore, you
can determine the toxin. it's when you have a small, increased risk in a very common form of cancer like, let's say, breast cancer. to detect, it took a huge study to detect the very substantial but nonetheless rell thetively small relative risk of increase of breast cancer with hormone replacement therapy. now, again, this risk was large enough to even register on an epidemiological scale, so this was a large risk. but it takes a sophisticated kind of study to figure it out. so the quick answer to your question is, unfortunately, i'm not sure we're there yet in terms of technology, in terms of figuring out what these small, common risks are. i suspect that for some canners we'll never be -- cancers we'll never be there because in the end can one really determine whether this was a small risk created by a carcinogen, or was this a that muchal mutation.
for some cancers i think it's going to be very, very, very difficult. >> thank you for that fascinating talk and fascinating reading. >> oh. >> you talked about how radical mastectomy was institutionalized as a treatment for breast cancer, and it took 90 years to understand that it was unnecessary and ineffective. um, i wonder if you can talk about any other examples of that that you've come across in your research, and in particular are there treatments that are part of standard therapy now that ten years from now or 2007 or fifty or ninety we will think of as ineffectual or unnecessary? >> i certainly hope so. [laughter] well, i mean, there are many examples, and actually i talk about these. i mean, one of the things in writing this book, and i know this was commented upon is i also wanted to not write a so-called whig history in which, you know, progress leads to more
progress and one ends up in a sunny place. in fact, there are very dark moments and dark histories, dark stories in this book. and many of the dark stories have to do with the way medicine becomes a self-fulfilling prophesy or learns to believe in itself. radical mastectomy is one of them that, believe it or not, back to breast cancer, in the 1980s there was a strong sentiment that many researchers believed that giving radical chemotherapy would cure breast cancer, and so radical that, in fact, you'd wipe out your bone marrow and have to replace it with your own bone marrow that had been frozen away. and it took another decade to disprove that. and part of the reason was that patients didn't want to enroll themselves in the trials. so patients had become so convinced that -- by their doctors, they'd become so convinced this was the right thing to do, that no one wanted
to be randomized to the placebo arm of this trial. the doctors said why go through this randomization? so, you know, in massachusetts -- this would be interesting -- in massachusetts there was a law that was passed called charlotte's law which forbade an insurance company from not allowing bone marrow transplantation for breast cancer. in other words, it was felt the insurance companies would skimp, which they were doing, on breast cancer therapy. there was a law that was passed. basically, it was breast cancer therapy with transplantation mandated by law. there are example after example, and i certainly think this will repeat itself for many forms of therapy that we engage in today. >> i have a question on prostate cancer. >> yeah. you may have to be loud, because the mic is somewhere in the
back. i can repeat your question. >> [inaudible] >> well, are you asking what ultimately causes prostate cancer or why does it come in so many different varieties? which of those? >> [inaudible] i'm getting older. [laughter] developing prostate cancer is, you know, very high -- >> that's right. >> yeah. >> causing that large number of -- >> i think we don't know the full answer to that question. it turns out that the prostate is one organ where malignancy develops in men at a remarkably high rate. what's very tricky about prostate cancer is that it comes in many different forms. there's one form that actually does not metastasize so easily, and in fact, you will not die with prostate cancer, and there's another form that will kill you. and we've not begun to figure out how to discriminate between
these two things, and it's a huge problem. it's a problem that is, again, of the magnitude that it will make a difference, it's a kind of problem that will make a difference in the national health care budget because for every 10,000 of the one kind that you shouldn't be treating anyway, you're treating, you know, you're piling up costs, biopsy costs, treatment costs where the best thing to do is actually not do anything. that's part of the answer. of course, there's a cultural part of the answer, and in that absence of that knowledge -- this is what i talk about this book -- in the absence of the knowledge how do we behave as individuals or a society? how does one, for instance, tell a man that i'm not sure but it's likely, there's about 85% likely that your prostate's going to be the untreated kind, why don't you watch and wait? in a culture where the word cancer has taken on the current metaphors and the current
understanding, how does one communicate the complexity of that idea, and who's comfortable and not comfortable with it? you know, if you go on the web, you will find 10,000 opinions about testing with a p is sa, right? and, again, this is of, this is of enough importance and so common that it will make a difference to the budget because the numbers pile up. so, again, the usual answer to this is, my usual answer to this is technology, science, deeper understanding. while the, while we are in this sort of waiting pattern trying to figure out what hopefully a few in the audience will tell us five years later how to discriminate between the so-called good kind and bad kind of prostate cancer and relieve all these problems that you're having in washington. so encourage technology, encourage science. that's the best thing we can do.
yes. >> [inaudible] >> i -- yeah, have we looked at, do i talk about the food additives and hormones? i actually spent a little bit -- i spoke a little bit in the book about cardiology fist estrogens and pesticides. but, you know, it's an issue that really remains -- i haven't looked at it, but there's a deep interest in hooking at it, in particular at pesticide. and, again, i think this is the kind of integrated approach involving not just the old style epidemiology, but a combination of no clerk lahr -- no clerk lahr biology would be required to solve these puzzles. in general i think especially
there's a bit of a smoking gun there. i don't know if people agree or disagree with that. questions in the back and then maybe in front. >> i was wondering if you could comment on your evolution as a writer, a little different tact. >> um, in the sense of -- >> well, was this your first book? the an extraordinary book. i'm just curious how you evolved as an author. >> um, you know, my general approach to writing this book or to any kind of writing that i do happens to be informed from, think -- through my scientific work is i like to write books that answer questions. and in this case i had a very urgent question.
in terms of writing this particular book, i actually learned to write while i wrote this book. and if you are a reader of this book, in fact, you might sense that as the book progresses from the second, from the 200th page to the 400th page, again, if you're a very careful reader, to me it's quite obvious that i'm learning to write as i'm doing this. [laughter] by the 400th page, i'm a different writer than i am from the first page. now, i worked backwards, and i tried to clean up what i had done before, but again, that mark still remains, and i do realize that writing itself evolves. so that's one, that's one feature of it. in terms of process, you know, i talked about, i've spoken to others already about this, and it's been written about, i am a deeply indices palined writer in the sense that i write sort of small snatches here and there.
often -- i write exclusively in my bed. [laughter] i prop myself up with pillows and, you know, when i was writing all of this, often i would have the early mornings i would write when i could have, i had a sort of -- um, and i think the most important thing in terms of the writing of this book, and, again, if you're a writer it becomes, i think, clear to you. this book lives at its what i call the seams, and by that i mean the content was relatively easy for me to write. it was the stitching together of the content. so, in other words, how does one go from 1994 back to 2000 b.c. and then move forward to 500 a.d.? what were the seams, how does this fit together, and sometimes
that stitching is very tenuous. and it's, so, in fact, the real discipline in this book, in this particular book was that stitching; how does one manage? and the answer to that is that i tried to imagine a very confident can reader. i -- confident reader. i tried to say to myself the kind of person who will go through this book is the kind of person i trust to move through those seams, and i will rise to the book, and i will rise to read it. and i'm not going to make some kind of compromise about it. and people who read the book, it gets into pretty -- the science gets pretty dense. i didn't spare the most contemporary details. i mean, we talk about, we talk about cancer genomics from 2008. so this, it gets really complicated. but, again, it lives, the book lives in its seams. so those were the features that, um, allowed me to be, you know,
to write. one last comment, and that is that lots of people have asked me, i mean, i've been asked to rival is actually a friend, and so i learned to write from people who have written about medicine before me. so there was a learning process reading, a lot of reading, and that raises the question about -- which is a very interesting question to me, personally, which is that was there something about being indian in this book, in this particular book? and, you know, the fact is i also happen to be from the subcontinent. so i was spending a lot of time thinking about this, and my answer to the question is i think, um, i think the most important thing about being indian in writing this book was the fact that india gave me the freedom not to write about
india. and in doing so allowed me to write about something that was entirely universal, had nothing to do -- but it was almost as if i inherited a kind of writing tradition which allowed me to not have to write about the local politics or the churl of a -- culture of a subcontinent but something you and i can have a conversation about. and that freedom was very important to me, personally. it's a culture freedom, a political freedom, and i'm not sure i can convey how deeply that was important to me. i felt i could write about something that's relatively universal, and i thank, actually i thank being in america for that, i also thank the political freedoms of my country. countries. yes. maybe i'll take a last couple of questions. last question maybe. two questions. yes. >> in recent years there's been a lot of research into --
[inaudible] , and i was wondering why you didn't include it in your book, and do you think any therapies will come out of this research to fight against cancer? >> yeah. so, again, this question goes back to the question of what was included and not included in the book. in general, i included scientific things in the book that have led to human therapies. i tried to avoid -- o so, in other words, if you really trace back everything that's in the book, whatever goes into the book really ends up in a human being somehow. comes out of a certain genetic understanding of cancer and becomes a drug. preventative mention nhl, things like an understanding of metastasis, things like the immune system, i think they are very important in the
understanding of the fundamental biology of cancer but did not meet that sniff test of being able to be transformed into something that will impact the way we either treat or the way we deal with in preventative mechanisms of cancer. when they do so, i mean, i'll be forced to write an addendum to this book. [laughter] and the last question. >> when my uncle had leukemia, they told him at johns hopkins university and beyond this it was something greater. how much do you think, like, either positive mental attitude or belief in, you know, some sort of spiritual thing plays a role in curing cancer? and what is your experience in all the patients that you saw? >> right. well, i have -- it's good that we're going to end with that question because i'm going to give a relatively provocative answer. my provocative answer to that is i try not to believe that the psyche has a role in causing
cancer for the following reason: because i think it victimizes cancer patients. so when people say, oh, you know, there's a link between the psyche and cancer, i think it's precisely the kind of link that hands to a cancer patient whose plate is already full twice the burden of their disease. so i, i try to shy away from that kind of thinking because it feels to me very negative in some ways. i know plenty of people who have had intensely positive attitudes about life who have had incurable cancers, and i know plenty of people who are unbelievably depressed or have all sorts of mental illnesses who have lived perfectly healthy cancer-free lives. so this idea that the psyche causes cancer, i have kind of an allergy to that idea. now, that said, do i believe the psyche modifies one's ability to heal? yes. now, but there's no archetypal
psyche. in fact, someone might use grief to heal, someone might use depression to heal. for someone tealing with their -- dealing with their illness might involve entering a space that's filled with grief and depression. that might be their mechanism. and to force my understanding of whatever specialty is, to force my understanding of what a positive understanding is, again, i think ends up victimizing a patient. who am i to say what yours positive attitude is? your decision, you might decide that you're intensely, you have an intense feeling of grief around your illness, right? that's your mechanism of healing. i can try to, i try to help people when that grief takes what i would call kind of a pathological form. but even then i try to be kind of, i try to step back from it. and i particularly am allergic to this idea that, oh, you know, the reason you're not getting better is because you're not thinking positively enough.
i think, actually, that's part of the reason i actually wrote this book. there are so many self-help books out this about cancer that say that, that, you know, you're not getting better enough, you're not doing the right thing, you're not fighting hard enough. and i think i'm very allergic to that. i'm not going to go there. if that's where you wanted to be, that's your decision as a patient. i respect that decision, but for me to say that as a doctor, i think, creates a kind of cycle of blame that i really want to avoid. thank you. [applause] >> sid hard that knew carry is a staff fission at columbia university medical center. the author of the emperor of all maladies and the winner of the 2011 pulitzer prize in general nonfiction. to find out more and other pulitzer prize winners, go to pulitzer